CMS Five Star Best Practice Review

1. CMS Five Star Best Practice Review Kaiser Foundation Health Plan Marcella Jordan, Vice President Medicare & Compliance Programs September 5, 2012

2. Overview Background Review Process & Protocols Compliance Program Best Practices

3. Background • For 2012, four of KFHP’s Medicare health plans were awarded an overall rating of 5 stars • California, Colorado, Hawaii, and Northwest • Combined membership of over 900,000 • Integrated health systems inclusive of health plan, hospitals, and affiliated medical group • Operations largely decentralized • National Compliance Program in place

4. Review Process & Protocols: Approach • Formal notification received February 6, 2012 • Conducted in two phases • Compliance Program was only area reviewed on-site

5. Review Process & Protocols: Timeline

6. Review Process & Protocols: Preparation • Universe/supporting documentation request included with engagement letter • Samples received just a few days in advance or on same day depending on element • Moving forward, sample selection to be provided on day of audit • Reviews conducted via webinar • Live “walk-though” of systems • All documents uploaded through secure File Transfer Protocol (FTP)

7. Review Process & Protocols: Challenges • Short turnaround times to produce: • Universes, supporting documentation • Coordination (i.e. ensuring right people available at the right times) • Securing necessary information/files from vendors • Technical difficulties • Viewing/opening large files via webinar • Navigating complex data systems in real-time • Playing audio recordings (e.g. OEV calls) over webinar

8. Review Process & Protocols: Lessons Learned • Secure leadership support to ensure adequate resources • Have WebEx savvy people available to facilitate meetings • Ensure electronic versions of documents are available for quick retrieval and effective archiving • All hands on deck!

9. Compliance Program Best Practices • KFHP passed all eight Compliance Program elements • Seven OIG elements and FDR • Compliance Program was previously audited in Fall 2010 • Numerous best practices cited by CMS

10. Compliance Program Best Practices Data Mining • Analytic team dedicated to data mining • Identifies patterns that suggest FWA; refers cases as appropriate • Conducts ad-hoc studies based on tips • Monitoring of claims paid in CMS-designated “high-risk Counties”

11. Compliance Program Best Practices Tracking of FDR Training • Training for our Medical Groups: • Offered through web-based modules • Completion tracked at individual level

12. Compliance Program Best Practices • Receives 7,000 calls per year • Integrated with case tracking system • System also tracks all CAPs and disciplinary actions • Controls allow for triaging and active monitoring of open cases Compliance Hotline

13. Compliance Program Best Practices • Regulatory guidance is reviewed and internally disseminated • Implementation of new requirements tracked in a database New CMS Issuance process

14. Compliance Program Best Practices • Interactive website that allows employees to add comments or pose questions • Site showcases policies, procedures, and compliance toolkits Code of Conduct

15. Contact Information Marcella Jordan, VP- Medicare & Compliance Programs Kaiser Foundation Health Plan, Inc. 2101 East Jefferson Street, 2W Rockville, MD 20852 Office: (301) 816-7178 Mobile: (202) 744-0233 marcella.jordan@kp.org

16. Questions & Answers Thank you!